Wuerzner, Grégoire

Burnier, Michel

Murang'a University of Technology

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1054 American Journal of Hypertension 26(8) August 2013Response to LetteR to editoRResponse to “Assessment of Blood Pressure Dipping: Is the Evaluation Method Important?”Grégoire Wuerzner1,2 and Michel Burnier1Correspondence: Grégoire Wuerzner (gregoire.wuerzner@chuv.ch).1Service of Nephrology, Lausanne University Hospital, Lausanne, Switzerland; 2Centre de Recherche Clinique, Lausanne University Hospital, Lausanne, Switzerland.Initially submitted May 22, 2013; accepted for publication May 23, 2013.doi:10.1093/ajh/hpt097© American Journal of Hypertension, Ltd 2013. All rights reserved. For Permissions, please email: journals.permissions@oup.comTable 1. Step count across different dipper categories for systolic and diastolic blood pressure dippingStep  countaReverse  dippers Nondippers DippersExtreme  dippersP for trend1 4,460 ± 1,960 6,760 ± 2,960 8,960 ± 3,540 7,910 ± 3,740 0.0232 4,740 ± 1,880 6,350 ± 2,530 8,740 ± 3,880 8,250 ± 3,620 0.007Data are presented as means ± standard deviation.a1: dipping categories based on systolic blood pressure dipping. 2: dipping categories based on diastolic pressure dipping.To the Editor: We appreciate the interest of Dr Sobiczewski and Dr Wirtwein in our study “Step Count is Associated With Lower Nighttime Systolic Blood Pressure and Increased Dipping.”1 This study, which included patients referred for ambulatory blood pressure (ABP) monitoring, shows that step count is associated with lower nighttime systolic blood pressures (BP) and increased systolic and diastolic BP dipping. In a second-ary analysis, we showed that the step count increases from reverse dippers to extreme dippers using mean BP to categorize the participants’ dip-ping status. It is true that most clini-cal trials on the prognostic value of BP dipping have focused on systolic BP rather than mean or diastolic BP because, with age, there is a gradual shift from diastolic BP to systolic BP as predictors of coronary heart dis-ease.2 In our study, which included young to elderly participants, replac-ing mean BP dipping by systolic or diastolic BP dipping to categorize dip-ping status did not change the associa-tion between step count and dipping categories (Table 1).It is true that ABP is not necessary to diagnose hypertension according to European Society of Hypertension guidelines. However, this is essentially for practical reasons: cost and avail-ability. The prognosis value of ABP is undoubtedly more accurate than office BP,3,4 and some of the latest guidelines, such as those of the National Institute for Health and Clinical Excellence (NICE), have recommended a wider use of ABP.5 In this regard, we would like to emphasize that the prevalence of white coat hypertension and masked hypertension in our participants with-out antihypertensive treatment was 22% and 27%, respectively. Misclassifying patients may result in unnecessary treatments or failure to treat patients at risk.Data about secondary hypertension or the timing of drug taking, which are known to affect BP dipping, were not recorded in this study. An influence of these variables on BP dipping can there-fore not be excluded. Blockers of the renin angiotensin system, beta- blockers, calcium channel blockers, and diuretics were not associated with BP dipping. However, the study was not designed to answer this specific question and may therefore not be sufficiently powered to resolve this issue.DiSCLoSUReThe authors declared no conflict of interest.RefeReNCeS 1. Wuerzner G, Bochud M, Zweiacker C, Tremblay S, Pruijm M, Burnier M. Step count is associated with lower nighttime systolic blood pressure and increased dipping. Am J Hypertens 2013; 26:527–534. 2. Franklin SS, Larson MG, Khan SA, Wong ND, Leip EP, Kannel WB, Levy D. Does the rela-tion of blood pressure to coronary heart dis-ease risk change with aging? The Framingham Heart Study. Circulation 2001; 103:1245–1249. 3. Dolan E, Stanton A, Thijs L, Hinedi K, Atkins N, McClory S, Den Hond E, McCormack P, Staessen JA, O’Brien E. Superiority of ambula-tory over clinic blood pressure measurement in predicting mortality: the Dublin Outcome Study. Hypertension 2005; 46:156–161. 4. Sega R, Facchetti R, Bombelli M, Cesana G, Corrao G, Grassi G, Mancia G. Prognostic value of ambulatory and home blood pres-sures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) Study. Circulation 2005; 111:1777–1783. 5. Krause T, Lovibond K, Caulfield M, McCormack T, Williams B. Management of hypertension: summary of NICE guidance. BMJ 2011; 343:d4891.

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